Texas > Workers Compensation > Employee
Application For Supplemental Income Beneifts DWC-52 - Texas
| Application For Supplemental Income Beneifts Form. This is a Texas form and can be used in Employee Workers Compensation . |
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First Quarter: File with Local Office Handling Claim Subsequent Quarters: File With Insurance Carrier CLAIM # _________________________________________ Carrier's Claim No. ___________________________________ APPLICATION FOR SUPPLEMENTAL INCOME BENEFITS To Employee: You must file an Application for Supplemental Income Benefits for a determination to be made on whether you are entitled to receive supplemental income benefits. You may file the form by first class mail, personal delivery or facsimile. Only for the first quarter, return this form to the Division's local office handling your claim. For all subsequent quarters, return the form to the insurance carrier 14 days before the beginning of the quarter for which you are applying for benefits. For the qualifying period (see dates in Step Two, Block 4 below), you must provide documentation that you earned less than 80% of your average weekly wage as a direct result of your impairment from the compensable injury. You must attach copies of supporting payroll documentation (paycheck stubs, employer statement(s) or other valid documentation) of your wages for the qualifying period. If you are not working, you must in good faith look for a job that matches your ability to work in every week of the qualifying period. STEP ONE: EMPLOYEE INFORMATION 1. Employee's Name (Last, First, M.I.) 3. Telephone Number ( ) 5. Date of Injury 4. Social Security Number 6. Impairment Rating 2. Mailing Address (Street or P.O. Box) City State ZIP Code 7. Date of Maximum Medical Improvement 9. Current Treating Doctor's Name and Telephone Number ( ) 11. Adjuster's Name and Telephone Number ( ) 8. Employer's Business Name on Date of Injury 10. Insurance Carrier's Name STEP TWO: REQUIRED GENERAL INFORMATION This form must be filed no later than the filing deadline shown in Block 2 below. Late filing will delay any possible payments and may result in a reduced payment. If the form is received by the insurance carrier earlier than 20 days before a subsequent quarter begins, it will be returned to you to resubmit no later than 7 days before and no earlier than 20 days before the beginning of the quarter (Block 3 below). Read all questions and instructions carefully. 1. Quarter Number: 3. Dates of Quarter: Beginning: Ending: 2. Filing Deadline: 4. Dates of Qualifying Period: Beginning: Ending: Yes No 5. Did you earn any wages or have any job offers during the qualifying period shown in Block 4? If yes, you must complete Step Three (page 2) and attach documentation. 6. If you are not currently working, are you able to work in any type of job in any capacity? Yes ____ No ____ If yes, you must look for work that matches your ability to work every week of the qualifying period (dates in Block 4) and document your job search in Step Four (pages 2 and 3). If no, see Block 8 below. 7. Are you enrolled in, and satisfactorily participating in, a full-time vocational rehabilitation program sponsored by the Texas Rehabilitation Commission or a private provider that is included in the Registry of Private Provider of Vocational Rehabilitation Services? Yes____ No____ If yes, this may be considered a good faith effort to find a job that matches your ability to work. Please attach documentation to show your participation and progress in the program. For example, this may be a letter from your TRC counselor or instructors and a copy of your college registration or grades (if applicable). 8. Has your doctor documented that you cannot do any type of work in any capacity? Yes ____ No____ If yes, you must attach a current medical report from your doctor that specifically explains how the injury prevents you from doing any type of work. There can be no other records showing that you are able to return to work. The information I have provided on this Application for Supplemental Income Benefits is true. I understand that if I intentionally provide false information to obtain benefits, I can be charged with an administrative or criminal penalty. Employee's Signature Date NOTE: With few exceptions, you are entitled by law to know, review, and correct information that DWC collects on its forms about you. For more information, call our Open Records section at 512-804-4437. DWC FORM 52 (Rev. 10/05) Page 1 of 4 DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.USCourtForms.com CLAIM # _______________________________________ Carrier's Claim No. __________________________________ Employee's Name Social Security No. _____________________ Date of Injury ____________________ STEP THREE: WAGES DURING QUALIFYING PERIOD (see STEP TWO, BLOCK 4 for dates) The qualifying period is a 13-week period in which your wages are reviewed to determine whether you are entitled to receive supplemental income benefits. If you are able to work in any capacity and are employed, you must report your earned wages by attaching a copy of paycheck stubs, employer statement(s) or other documentation for this qualifying period. If you have any offers of employment which you do not accept, you must include information about the offered wages as part of this application. If you are self-employed, show your gross weekly wages as the total amount of income received from self-employment. You also should attach additional information on the normal and fixed expenses of the business. If no wages were earned during a specific week, write "none." IMPORTANT: If you earned less than 80% of your average weekly wage, were your reduced earnings a direct result of the impairment from the compensable injury? Yes ___ No ___ Week Ending 1. 2. 3. 4. 5. 6. 7. Gross Wages Earned $ $ $ $ $ $ $ Week Ending 8. 9. 10. 11. 12. 13. Gross Wages Earned $ $ $ $ $ $ STEP FOUR: JOB SEARCH EFFORTS DURING QUALIFYING PERIOD (Continued on Page 3) If you have not returned to work and you are able to work in any capacity, you must look for a job to match your ability to work during every week of the qualifying period (see dates in Step Two, Block 4 on page 1). You must carefully and completely document your job search efforts. You must keep the kind of information shown below. If necessary, attach additional pages with this same information to keep track of all your job search efforts. It is recommended that you keep a copy of all job applications or resumes you turn in to companies during each qualifying period to support your search efforts. If you do not keep complete records, you may not be given credit for the searches. Job search document
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